Fast atrial arrhythmias such as AF and AT are abnormal heart rhythms which afflict around three million people each year in the United States. The most prevalent evidence of the disease electrically is a preponderance of irregular AF wavelets of activation that is frequently generated in the pulmonary veins [PVs] and is conducted into the left atrium and then the right atrium causing chaotic and rapid activation that interferes with the normal SA/AV cardiac electrical pathways and causes rapid, irregular ventricular contractions. These atrial tachycardias can be in the form of atrial fibrillation or atrial flutters, typical and atypical, which may vary in terms of severity and rate. AF makes the ventricular response so irregular and fast that it interferes with normal blood flow through the heart chambers, can lead to severe structural heart disease, and can be life-threatening if not treated effectively. While the irregular rate of ventricular contraction during AF and AT may compromise cardiac output and cause fatigue, much of the increased mortality associated with AF is due to clot formation due to the poor circulation in the atria that embolizes to cause stroke, renal infarcts, etc. Persistent AF over weeks or months is particularly dangerous.
There are a number of known modalities for treating atrial tachycardias. The “Maze Procedure” was developed many years ago and affects a cure rate of at least 90% for AF. This procedure involves “cutting” surgical lines or patterns in the right and left atria [RA and LA] to interrupt unwanted conduction pathways that cause AF. The drawback to this procedure is that it requires open heart surgery and is usually performed on a patient only if there is another more important reason to enter the heart via major surgery, such as a valve replacement or a similar procedure.
RF/microwave ablation, cryo-ablation, ultrasound ablation, or variants of the Maze Procedure are used to burn, freeze, or cut and score lines in the right and left atria. Ablation is performed inside or just outside the pulmonary veins (PVs) and ostia in an attempt to interrupt sources of activation wavefronts that arise in the PVs and propagate into the atria and lead to AF and AT. There is strong empirical evidence that micro-re-entrant electrical signals emanate from the lungs via the pulmonary vein nerve cables and conduct unwanted wavelet noise signals into the LA and RA that are largely responsible for AF. Other points of interest within the left atrium of the heart that are targets of RF ablation procedures are the ostia and ganglionated plexi. The left atrial appendage and Ligament of Marshall may also be removed epicardially via limited thoracotomy to remove unwanted circuit pathways and to prevent clots from forming [left atrial appendage].
There are concerns and known side effects such as esophageal fistulae and stenosis of the PV ostia as a result of these ablation procedures. Each case is unique in that there are infinite combinations of tissue conduction pathways and electro-physiologic anomalies and differences within each person that cause the wavelet trains that cause AF and atrial flutter. Knowing where to ablate the tissues of interest is difficult, at best. Also, the cure rate is less than optimum for persons with chronic AF and severe structural heart disease as compared to persons with paroxysmal or occasional/idiopathic AF/flutter. It is also difficult to make the long ablation lesions continuous and transmural.
Another procedure to treat AF tachycardia is DC cardioversion shock therapy to convert AF/flutter to sinus rhythm. This is an excellent conversion tool; however, unless the underlying cause of the AF is resolved, it most likely will recur. Implantable cardioverter defibrillators [ICDs] have been used for conversion of AF, but since the patient is conscious when the shock is delivered, many individuals find the discomfort of the shock intolerable. These systems generally use a “hot can” approach where a very high voltage and current are delivered through the heart and the left chest and pectoral areas, causing significant pain during a defibrillation or cardioversion shock. One advantage of an ICD with AF cardioversion capability is to reduce the amount of time that AF persists before cardioversion to reduce the risk of clot formation.
Anti-arrhythmia drug therapy is effective in many cases even if the AF is not entirely converted back to a normal sinus rhythm. A primary cause for concern is that these drugs are systemic and affect other systems such as the liver, kidneys, and heart, and can also cause fatigue associated with loading and maintenance doses of these drugs.
In patients who do not respond to medications and who are not good candidates for the previous methods for curing or controlling AF, the AV node may be ablated to create complete heart block so that the rapid, irregular atrial activations do not propagate to the ventricles and a pacemaker is implanted to control the heart's rate and rhythm. Drawbacks with the use of pacemakers include possible lead fractures and the abnormal activation sequence they cause in the ventricles, which leads to an abnormal contraction sequence and decreased ventricular function.
Thrombolytic drugs in conjunction with anti-arrhythmic drugs are valuable to prevent thromboembolisms and slow the heart rate. However, long term use of thrombolytic agents may have side effects that can be serious such as hemorrhage.